HomeMy WebLinkAbout1649 Independence Rd - Applications/Reroof - 09/13/2017City of manning, Development & Transportation
281 N. College Ave P.O. Box 580
Flirt Collide Fort Collins, CO 80524
Phone 970-416-2740 Fax 224-6134
OVER-THE-COUNTER PERMITS ONLY
This application is to be used to apply for the following permits only heck all that apply). ❑ Air Conditioning
❑ Demolition (interior non-structural) ❑ Electrical Alteration (not servic hange) ❑ Gas Lighter ❑ Gas Log
❑ Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement oofing ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilation ❑ Water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicable information on the application. Incomplete applic/attiions will not be accepted.
Application # b I -710-15 11400 Date Q- (`, t R 7
For office use only � l
Job Site Address (required) Value of Construction (labor,
Property Owner Name Address City/State Zips
-_aru. 'i. alb-- lZ�"�
Applicant Name Address City/State Zip Phone
Contractor Address City/State Zip Phone
I
Contractor City of Ft. Collins Sales Tax # Are you playing taxes here or by report? ere El Report
Sales tax number is required by all contractors. Are you paying with your trust account? ❑ Yes ❑ No
Is this a residential or com ercial project? LKesidential ❑ Commercial
If residential, is it: Ingle Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain
Is this building 50 years of age or more? ❑ Yes o If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
of work
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List the company name or City of Ft Collins license #
Electrician Plumber
Mechanical Roofer
Other
I hereby acknowledge that I have read this application and state that the above information is complete and correct. I agree to
comply with all requirements contained herein and city ordinances and state laws regulating building construction. I know that a
permit is not valid until it has been paid and issued.
Applicant: 1
Print Name: T_)&5 ; ry ��( eC'i�Signature Date �_